Readiness of electronic health record systems to contribute to national health information and research

Transcription

1 Please cite this paper as: Oderkirk, J. (2017), Readiness of electronic health record systems to contribute to national health information and research, OECD Health Working Papers, No. 99, OECD Publishing, Paris. OECD Health Working Papers No. 99 Readiness of electronic health record systems to contribute to national health information and research Jillian Oderkirk JEL Classification: I1, O3, O5

2 Unclassified DELSA/HEA/WD/HWP(2017)9 DELSA/HEA/WD/HWP(2017)9 Unclassified Organisation de Coopération et de Développement Économiques Organisation for Economic Co-operation and Development 30-Nov-2017 English text only DIRECTORATE FOR EMPLOYMENT, LABOUR AND SOCIAL AFFAIRS HEALTH COMMITTEE Health Working Papers OECD Health Working Paper No. 99 READINESS OF ELECTRONIC HEALTH RECORD SYSTEMS TO CONTRIBUTE TO NATIONAL HEALTH INFORMATION AND RESEARCH Findings of the 2016 OECD HCQI Study of Electronic Health Record System Development and Data Use Jillian Oderkirk* JEL classification: I1, O3 and O5 Authorized for publication by Stefano Scarpetta, Director, Directorate for Employment, Labour and Social Affairs (*) OECD, Directorate for Employment, Labour and Social Affairs, Health Division. All health Working Papers are now available through the OECD's website at: JT English text only This document, as well as any data and map included herein, are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area.

3 DIRECTORATE FOR EMPLOYMENT, LABOUR AND SOCIAL AFFAIRS OECD HEALTH WORKING PAPERS OECD Working Papers should not be reported as representing the official views of the OECD or of its member countries. The opinions expressed and arguments employed are those of the author(s). Working Papers describe preliminary results or research in progress by the author(s) and are published to stimulate discussion on a broad range of issues on which the OECD works. Comments on Working Papers are welcomed, and may be sent to health.contact@oecd.org. This series is designed to make available to a wider readership selected health studies prepared for use within the OECD. Authorship is usually collective, but principal writers are named. The papers are generally available only in their original language English or French with a summary in the other. This document and any map included herein are without prejudice to the status of or sovereignty over any territory, to the delimitation of international frontiers and boundaries and to the name of any territory, city or area. The statistical data for Israel are supplied by and under the responsibility of the relevant Israeli authorities. The use of such data by the OECD is without prejudice to the status of the Golan Heights, East Jerusalem and Israeli settlements in the West Bank under the terms of international law. OECD 2017 You can copy, download or print OECD content for your own use, and you can include excerpts from OECD publications, databases and multimedia products in your own documents, presentations, blogs, websites and teaching materials, provided that suitable acknowledgment of OECD as source and copyright owner is given. All requests for commercial use and translation rights should be submitted to rights@oecd.org. 2

4 ACKNOWLEDGEMENTS This OECD study was undertaken by the OECD HCQI (Health Care Quality Indicators) Expert Group as part of the 2015/16 programme of work of the OECD Health Committee. The authors would like to acknowledge the representatives of the countries who make up the HCQI Expert Group, all of whom gave generously of their time to provide input and guidance to this study. Additional thanks and recognition is extended to the experts from participating countries who provided responses to the survey upon which this study is based. The OECD would like to acknowledge the contributions of Jillian Oderkirk, Niek Klazinga, Luke Slawomirski, Lukasz Lech and Duniya Dedeyn who endeavored to make this report possible. Appreciation is extended to Stefano Scarpetta, Mark Pearson and Francesca Colombo for supporting and directing this study. 3

5 ABSTRACT All countries are investing in the development of electronic health (clinical) records, but only some countries are moving forward the possibility of data extraction for research, statistics and other uses that serve the public interest. This study reports on the development and use of data from electronic health records in twenty-eight countries. It reports on the prevalence of technical and operational factors that support countries in the development of health information and research programmes from data held within electronic health record systems, such as data coverage, interoperability and standardisation. It examines data quality challenges and how some countries are addressing them and it explores the governance of electronic health record systems and data, including examples of national statistical and research uses of data. The report provides an overall assessment of the readiness of countries to further develop health information from data within electronic health record systems and describes the outlook for the future. Ten countries are identified as having high readiness that enables them to develop world-class health information systems supporting health system quality, efficiency and performance and creates a firm foundation for scientific research and discovery. RÉSUMÉ Tous les pays investissent dans le développement de dossiers médicaux électroniques, mais seuls certains parmi eux avancent la possibilité d'extraire des données à des fins de recherche, de statistiques ainsi que d'autres utilisations servant l'intérêt public. Avant tout, la présente étude rend compte de l'évolution de l'utilisation des données de santé provenant des dossiers médicaux électroniques dans vingt-huit pays. Elle fait état de la prévalence des facteurs techniques et opérationnels qui aident les pays dans le développement des programmes d'informations et de recherche sur la santé à partir de données détenues dans les systèmes électroniques de données de santé, tels que la couverture des données, l'interopérabilité et la normalisation. Deuxièmement, en examinant les défis liés à la qualité des données et la façon dont certains pays les relèvent, cette étude évalue la gouvernance des systèmes et des données électroniques de santé incluant les exemples d'utilisations des données nationales à des fins statistiques et de recherche. Enfin, ce rapport donne une évaluation globale de la disponibilité des pays à développer davantage d'informations sur la santé à partir de données provenant des systèmes électroniques de dossiers de santé et il décrit les perspectives pour l'avenir. Dix pays ont été identifiés comme étant prêts pour développer des systèmes d'informations sur la santé de classe mondiale qui soutiendraient la qualité, l'efficacité et les performances des systèmes de santé et créeraient une base solide pour la recherche et la découverte scientifiques. 4

6 TABLE OF CONTENTS ACKNOWLEDGEMENTS... 3 ABSTRACT... 4 RÉSUMÉ... 4 INTRODUCTION OECD Study of Electronic Health Record System Development and Data Use TECHNICAL AND OPERATIONAL FACTORS SUPPORTING STATISTICAL AND RESEARCH USES OF EHR DATA Use of electronic clinical records in physician offices and hospitals is improving Most countries are implementing one country-wide electronic health record system s can access their own electronic health records in over half of countries Minimum datasets defined in 26 countries Use of structured data Use of cloud computing services is low Widespread use of a unique patient ID number in electronic health records DATA QUALITY CHALLENGES THAT LIMIT DATA USE AND EFFORTS TO ADDRESS THEM Most countries are challenged by multiple standards in use for the same key data elements Most countries have a national authority responsible for the EHR system that sets and maintains national standards Efforts to address the consequences of multiple minimum dataset specifications Policy levers requiring or encouraging adoption and maintenance of high quality electronic health records Quality auditing of clinical record content Technical and financial constraints limiting dataset development HEALTH DATA GOVERNANCE READINESS VARIES GREATLY AMONG COUNTRIES Data uses within national plans and policies OUTLOOK FOR THE FUTURE Strategic investments to advance the availability of data from EHRs for health system monitoring and research Outlook for the future International cooperation supports harmonisation toward common best practices REFERENCES ANNEX ANNEX ANNEX

7 INTRODUCTION 1. Countries that develop electronic health record systems that combine or virtually link data together to capture patients health care histories have the potential to realise an unprecedented advancement in health care quality, efficiency and performance and in the discovery and evaluation of preventative care and treatments, including precision medicine. The depth and breadth of such data far exceeds that available from traditional survey, administrative or research sources and supports new big data research techniques that can search for patterns and anomalies in populations (Figure 1). 2. Further, when longitudinal EHR data can be linked to information about treatment costs and deaths; such data then supports detecting unsafe health care practices and treatments; rewarding high quality and efficient health care practices; and detecting fraud and waste in the health care system (OECD, 2013, 2015a). 3. When longitudinal EHR data can be linked to patients behavioural, environmental and biological (genetic) characteristics; such data then supports identifying optimal responders to treatment and personalising care for better patient outcomes; and discovering and evaluating new health care treatments and practices. If such data is available for very large and representative patient populations, then it can support selecting cohorts of patients for clinical trials; and conducting long-term follow up of clinical trial cohorts (OECD 2015b, 2015c). Figure 1: Multiple uses of data within clinical electronic health record systems Source: Jensen, P.B., L.L. Jensen and S. Brunak (2012), Mining Electronic Health Records: Towards Better Research Applications and Clinical Care, Nature Reviews Genetics, Vol All countries are investing in the development of electronic clinical records, but only some countries are moving forward the possibility of data extraction for research, statistics and other secondary uses. Those progressing toward analytical uses of data are overcoming challenges ranging from ensuring adequate financial and human resources, to managing culture change, to effective public engagement, to ensuring data usability, quality, security and privacy protection. 6

8 2016 OECD Study of Electronic Health Record System Development and Data Use 5. With a mandate from the 2010 meeting of OECD Health Ministers, the Health Care Quality Indicators Expert Group (HCQI) began surveying countries in 2011 regarding the development of national health data assets and their use to improve health, health care quality and health system performance (OECD, 2013). We found that while all countries are investing in data infrastructure, there were significant cross-country differences in data availability and use, with some countries standing out with significant progress and innovative practices enabling privacy-protective data use, and others falling behind with insufficient data and restrictions that limit access to and use of data, even by government itself. 6. This study included a survey of countries development and secondary use of data from electronic (clinical) health records that uncovered significant differences in the design, implementation and governance of EHR systems between the 13 countries whose national plans or policies called for at least four different data uses and the twelve countries who were planning on fewer or no secondary data uses. 7. In 2016, this survey was administered again to report on the current status of EHR implementations and data uses and to monitor progress since Twenty-eight countries responded to the survey including Australia, Austria, Canada, Chile, Croatia, Czech Republic, Estonia, Finland, France, Greece, Iceland, Israel, Japan, Latvia, Luxembourg, Mexico, New Zealand, Norway, Poland, Singapore, Slovakia, Spain, Sweden, Switzerland, United Kingdom and United States (Annex 1). Three members of the United Kingdom are included in this study: England, Northern Ireland and Scotland Eighteen of these countries also took part in this survey in 2012: Austria, Canada, Denmark, Estonia, Finland, France, Iceland, Israel, Japan, Mexico, Poland, Singapore, Slovakia, Spain, Sweden, Switzerland, the United Kingdom (England and Scotland) and the United States. For these countries, results from 2016 are compared with those of 2012, where appropriate. 9. In the HCQI studies, an Electronic Health Record (EHR) refers to the longitudinal electronic record of an individual patient that contains or virtually links records together from multiple Electronic Medical Records (EMRs) which can then be shared (interoperable) across health care settings. It aims to contain a history of contact with the health care system for individual patients. 10. Part 1 of this report reviews the technical and operational factors that would support countries in the development of national health information and research programmes from data held within electronic health record systems. The factors examined include: Coverage of electronic health records; National EHR systems with comprehensive record sharing; data access; Minimum datasets; Use of structured data and clinical terminology standards; and Unique IDs for patients and providers in EHRs. 1 The data governance and operational and technical capacities of members of the United Kingdom have important differences that are of interest to OECD countries and, as a result, they are presented separately in this report. 7

9 11. The countries in the top tier with respect to technical and operational readiness to enable the statistical and research use of data from EHRs are identified. 12. Part 2 examines data quality challenges that limit data use and the efforts that have been made in some countries to address them. These include a lack of standards, poor record keeping practices, multiple definitions of the minimum dataset, and multiple terminology standards for the same data elements. This section describes national efforts to: Map data elements to a consistent terminology, Set national governance of clinical terminology and interoperability standards, Engage stakeholders in standards setting, Foster the use of one national minimum dataset, Legislate or incentive health care providers to adhere to standards, and Audit EHRs for clinical content quality. Technical and financial constraints that are limiting dataset development are also described. 13. Part 3 of this report explores the health data governance readiness of OECD countries. Factors examined include: Identification of statistical and research uses of data within national plans and priorities for EHR systems, Implementation of plans for data uses, Legislative frameworks that enable statistical and research uses of data, subject to safeguards, and Investments in national health information from data within EHR systems. 14. Datasets and statistical projects in leading countries are summarised and the top tier of countries with respect to health data governance readiness are identified. 15. Part 4 of this report concludes with an overall assessment of the technical, operational and health data governance readiness of countries to further develop health information from data within EHR systems and the outlook for the future, including recent strategic investments. Countries in the top tier for both data governance and technical and operational readiness are identified. The need for on-going monitoring at the international level and for harmonisation toward best practices are emphasised, so that more countries can benefit from data within EHR systems to improve health care quality, health system performance, patient experiences and outcomes, and to further medical research and other public policy objectives. 16. In parallel to these HCQI surveys has been an effort within the OECD to develop a questionnaire that could be used to benchmark internationally the development and use of information and communications technologies in the health sector. Unlike the HCQI project where country experts respond to the survey, this benchmarking effort is aimed toward surveying representative samples of health care providers and organisations within OECD countries in a comparable manner. First results from pilot data 8

10 collection in a large number of countries provides interesting insights that complement the findings of this HCQI study (See Box 1). Box 1: OECD project to internationally benchmark ICT adoption and use An OECD pilot study has compiled results for 38 countries for a subset of measures of the availability and use of information and communications technologies (ICT) in health care. 1 Data for the study were obtained from new or adapted country-specific or multi-national surveys of health care providers and organisations from 2012 to Data elements were selected for the study by assuring they matched or were comparable with a set of survey questions that were previously developed by the OECD for the international benchmarking of ICT adoption and use. The study found widespread use of electronic clinical records at the point of care; however, the exchange of electronic clinical records across health care organisations and settings was less common. There were also large variations in the availability and use of telehealth services across countries, such as services linking patients living in rural and remote locations to their health care teams via the use of technologies. Also, in many countries, patients were not able to access their test results online, book appointments electronically, renew prescriptions electronically or exchange secure messages with their health care providers. 1 Zelmer J, Ronchi E, Hyppönen H et al (2016), International health IT benchmarking: learning from cross-country comparisons, Journal of the American Medical Informatics Association, 22 August. 9

11 Finland Singapore Estonia Slovakia UK (England) Austria Canada Denmark Israel UK (Scotland) USA Luxembourg New Zealand Sweden Croatia Iceland Norway Spain Australia Latvia Poland France Chile Switzerland Greece Czech Republic Japan Mexico UK (Northern Ireland) Ireland DELSA/HEA/WD/HWP(2017)9 1. TECHNICAL AND OPERATIONAL FACTORS SUPPORTING STATISTICAL AND RESEARCH USES OF EHR DATA 17. This study examined a set of key technical and operational factors supporting the development of EHR systems that will contain high quality data that would be suitable for national monitoring and for research. These are among the same factors that would be considered when evaluating the quality of data within any statistical system and include: data coverage, completeness, accuracy, and usability. 18. Figure 2 presents a summary of where countries stand in relation to technical and operational readiness to support statistical and research uses of EHRs (See also Table 1 in Annex 2). Countries with the highest technical and operational readiness, such as Finland, Singapore, Estonia, Slovakia and England (United Kingdom) are in the best position to develop national health information from data within EHRs. This is not to indicate that all of these countries intend to advance the statistical or research use of EHR data, nor that they have the financial resources or plans in place to move forward, as will be further discussed in Section 3. Figure 2: Technical and operational readiness to provide national health information from EHRs Technical and operational readiness index (highest = 9) Note: Cumulative score of nine indicators each valued at one point: EMR coverage, information sharing among physicians and hospitals, defined minimum dataset, use of structured data, unique record identification, national standardisation of terminology and electronic messaging, legal requirements for adoption, software vendor certification and incentives for adoption (see Table 1 for the technical and operational readiness indicators). Source: HCQI Survey of Electronic Health Record System Development and Use,

12 1.1 The use of electronic clinical records in physician offices and hospitals is improving 19. OECD countries vary greatly in the degree to which general practice physician offices, medical specialist physician offices and hospitals are using electronic clinical records (Table 2). Countries with high coverage of the patient population will have a significant advantage in the development of health information from data extracted from EHRs. 20. Seventeen countries reported that at least 90% of hospitals are capturing diagnoses and treatment information within electronic patient records. Seventeen countries reported that at least 90% of primary care physician offices are capturing patient diagnosis and treatment information in electronic medical records. Fewer countries reported such a high penetration of electronic record keeping in hospital emergency rooms (13 countries) and in medical specialist physician offices (9 countries). 21. Conversely, Croatia, Mexico and Poland reported that less than one-third of primary care physician offices are using electronic medical records and Australia reported that less than one-third of hospitals are using electronic patient records for in-patients. Further, several countries lacked the data to estimate the penetration of electronic clinical record keeping, particularly for medical specialists (five countries) and hospital emergency rooms (eight countries). 22. Many countries with a low penetration of electronic clinical record keeping in 2012 were significantly improved in A near-doubling or better in the proportion of physician offices with electronic medical record keeping were reported in Canada, Denmark, Japan, Mexico, Poland, and Singapore. Similar gains were reported for medical specialist physician offices in Canada, Denmark, Japan, Poland and Spain; for hospital in-patients in Japan and Poland; and for hospital emergency rooms in Spain. 23. Further, data about the penetration of electronic record keeping has improved. Eight countries reported data in 2016 for categories where data were unavailable in Most countries are implementing one country-wide electronic health record system 24. Twenty-three countries reported that they are implementing an electronic health record system at the national level (Table 3). Most of these countries indicated that they are implementing or have implemented one country-wide EHR system. Countries not implementing, or not yet implementing, an electronic health record system at the national level are Chile, Croatia, Czech Republic, Denmark, Japan, Mexico, New Zealand and the United States. 25. Where capacity exists to identify a longitudinal patient history regarding diagnosis, treatment and outcomes there is fundamental strength enabling health information about health care pathways and outcomes One country-wide EHR system with comprehensive record sharing One patient, One record 26. Part of the benefits of electronic clinical record sharing includes enabling treating professionals to have a comprehensive view of their patients complete history of diagnosis, medications, procedures, laboratory tests, and medical images from the multiple providers that may have treated their patients. Such sharing reduces unnecessary duplication of tests and images, avoids inappropriate prescribing and can benefit more appropriate decision-making about treatment options. Further benefits of record sharing include more efficient service provision, through automated requests for referrals, admissions, medications, tests and images; and better communication with patients through record sharing portals. 11

13 27. Eighteen countries reported comprehensive record sharing within one country-wide system designed to support each patient having only one electronic health record (Table 3). These countries are Australia, Estonia, Finland, France, Greece, Iceland, Ireland, Israel, Latvia, Luxembourg, New Zealand, Norway, Poland, Singapore, Slovakia and United Kingdom (England, Northern Ireland and Scotland). In these countries, plans call for patient records to be shared among physician offices and between physicians and hospitals regarding patient treatment, current medications, and laboratory tests and medical images. Some have already achieved this functionality, while others are progressing toward it. 28. In Australia, the My Health Record system is a nation-wide electronic health record system that contains a summary of a patient's health information. information (in the form of clinical documents) are uploaded to the system by participating healthcare providers from across the private and public sectors. About one quarter of primary care physicians in Australia can electronically exchange patient summaries and test results with doctors outside of their practice. Most primary care physicians can, however, receive lab test and image results electronically. Medical specialist offices in Australia, however, are typically not exchanging information electronically. Australian states are in different stages of implementation of state-wide electronic records for hospitals, with the state of New South Wales being the most advanced and having integrated 100 hospitals within the state-wide EMR 2. All states have also begun sharing discharge summaries, diagnostic documents, specialist letters, prescription documents, dispense documents, event summaries, and shared health summaries within the national EHR system. In three states, the majority of hospitals are contributing to the national EHR system. 29. In Estonia, there is one national Health Information System (TIS). There are agreed data standards and functionalities in use at the locations where data are entered and the system is supported by an efficient framework for data processing that includes relevant national applications. The goal is to achieve the accessibility of standardised digital data for all users. In Estonia, primary care and medical specialist physician offices and hospitals are able to send and receive laboratory test or medical imaging results electronically; are able to see and update an electronic medications list for their patients that includes any current medications prescribed by other physicians; are able to see hospital in-patient and emergency room records for their patients electronically; and are able to see and update an electronic health record for their patients including diagnosis and treatment information from multiple physicians and over time. 30. Finland has a national electronic patient record depository and interoperable data while enabling health care providers to have their own EMR or EPR systems. Finland has fully implemented a national health information system for sharing patient data at the regional level and the system is obligatory for public sector primary care and medical specialist physicians and hospitals. Physician offices in the private sector are permitted to join the national system and their implementation into the system has started. Functionality includes sharing full plain text medical records, eprescriptions and sending and receiving laboratory tests and medical images; and medication lists. 31. France established a national shared patient record called the Personal Medical File (DMP) by law in The DMP is a computerised medical record that is created and accessed by health professionals with the consent of the patient. A patient s DMP includes diagnosis, treatment, emergency records, prescriptions, laboratory tests and imaging results, and hospital discharge summaries. The DMP system permits record sharing among primary care physicians, medical specialists, hospitals and with some health care workers, such as nurses and physiotherapists. The DMP has been available on-line since 2011 and by 2014 about files had been created. The DMP system was deemed to meet general information security standards (RGS) in For more information about the NSW Health EMR program, visit: 12

14 32. Luxembourg s primary care and medical specialist physicians and hospitals share patient summaries, laboratory test and medical imaging results, prescriptions and hospital discharge letters. 33. The EHR systems of every hospital and primary health care clinic in Iceland are interconnected enabling patient health information to be shared among different health care organizations country-wide. All health care providers have access to e-prescriptions and dispensed medication on a national level. All primary care physician offices and all hospitals share digital patient information across health care institutions and geographical boundaries. Electronic prescriptions and dispensed medications are shared on a national level among primary care physicians, medical specialists and hospitals. Medical specialist offices in Iceland benefit from the sharing of laboratory tests and medical images and physician referrals electronically but only some have electronic access to hospital in-patient and emergency room patient records. Preparations are underway now to fully connect medical specialists' offices. 34. The national health information exchange platform in Israel (OFEK) has been implemented in all acute care hospitals in all HMOs and in all public mental health and geriatric hospitals. Hospital medical specialists are in the process of being electronically connected to the platform. When specialists want to view all information on a patient, collected from all HMOs and hospitals in Israel, they can import the relevant data from the platform. Within each HMO, electronic patient records are shared among physicians and hospitals. Functionality includes requesting and receiving laboratory tests and medical images, maintaining medication lists, and diagnosis and treatment information. 35. Hospitals, primary care and medical specialists in New Zealand all have local or regional electronic medical records (EMR) that will share information with the national EHR. Currently most hospitals, primary care and medical specialists have local access to patient records including tests results, images, demographics, edischarge summaries, ereferrals and clinic letters. Primary care systems are largely electronic and some primary care physicians allow other health care providers, such as hospitals and emergency departments, to view patient information through a portal. Referrals and hospital discharge summaries are exchanged electronically between hospitals and primary care. Primary care physicians can transfer patient records to a new primary care practice electronically through a national information exchange system. Most primary care providers can access lab test results electronically and some can access medication histories. Hospitals and medical specialists within hospitals in New Zealand have access to patients electronic records including tests results, images, demographics, edischarge summaries, ereferrals and clinic letters. A few hospitals have electronic prescribing systems and can share a patients prescribed medicines. Some hospitals send out-patient clinic letters electronically. Most clinical notes, however, are still paper based in hospitals. Medical specialists outside hospitals have local EMRs that are not shared. They may, however, be able to access a central data repository to see test results and, in some cases, medical images. 36. Norway has had a national infrastructure for electronic messaging since 2004 (National Health Net) for primary care and medical specialist physicians. This includes electronic messaging for laboratory tests and image orders and replies; eprescriptions, electronic referrals to specialists and hospitals; and discharge summaries from hospitals. The national infrastructure extends to hospitals; however, not all hospitals have implemented the system or started using the functionality. Most hospital groups share a common EPR system but the sharing of electronic information across groups has been challenging and is a major driver behind the development of a new national ehealth strategy. 37. Poland is implementing the national Internet Account as part of the "Electronic Platform for Collection, Analysis and Sharing of Digital Medical Record" project. Some regions in Poland have developed a regional platform; however not all medical entities in those regions have joined them. In Poland, groups of primary care physicians concentrated within the same regional platform are sharing laboratory tests and imaging results. Two private healthcare networks are sharing medical record data 13

15 about visits and laboratory results among primary care and medical specialist physicians. Some hospitals that are concentrated within regional platforms, are sharing laboratory and medical imaging results with physicians in the same platform. There have been some interoperability standards created but there is not yet much sharing of data electronically in hospitals. Medical information exchange will advance in the near future as a regulation requires all providers to use electronic records by A country-wide National Electronic Health Record (NEHR) system has been implemented in Singapore and includes an Electronic Medical Record Exchange (EMRX) and a national database of patient allergy information. In Singapore, all public sector primary care and medical specialist physician offices share information nationally as part of a 'One, One Health Record' vision. There is an increasing proportion of private sector physician offices obtaining access to electronic information, although their contribution to shared information is limited by current IT capabilities. The sharing of electronic information among hospitals is facilitated through a centralised exchange solution for public sector institutions. 39. Information sharing among primary care and medical specialist physician offices and hospitals in the United Kingdom, England is intended to be comprehensive, however, not all physicians and hospitals have the full range of information sharing capabilities yet. In the United Kingdom, England, the national summary care record has been implemented and currently covers 96% of the population. 40. Similarly, the United Kingdom, Scotland has a summary of every patient's primary care record that is shared at national level. A single type of Management System is being implemented by National Health Service hospitals throughout Scotland although the functionality varies locally. There is no full national interoperability, and primary care, out-of-hours care and other sections of the health service use different systems. Clinical portals and data stores are in place for sub-national sharing of records, such as images and test results. Many parts of a patient's electronic health record are captured in systems which do not link to core National Health Service systems, e.g. community pharmacist and dentist systems. Summary patient records from primary care physicians, including a list of prescribed medications, are routinely shared with other parts of the health service including hospitals for all patients except those who have actively opted out. In addition, more extensive patient summaries are shared more widely for patients with long term conditions or complex care needs. Prescriptions from primary care physicians are electronically shared with dispensing pharmacists. Primary care physicians access hospital discharge letters, and most images and test results electronically. Similarly, medical specialists, who are all within hospitals, can view lab and imaging results through a central database either in a specific store or via clinical portals within hospitals. Hospital physicians and specialists can see key information from primary care records, including a list of medications prescribed, through routinely shared electronic summaries and hospital medical specialists in some regions can also view a shared patient record through a clinical portal. Most medical staff in hospitals are able to update patient records electronically but only those in a few areas in Scotland are able to update medications electronically as this is still mostly on paper. 41. In the United Kingdom, Northern Ireland has a shared electronic care record among primary care physicians, medical specialist physicians and hospitals that includes lab test and medical imaging results; discharge, clinic and primary care physician letters; patient care summaries; out-of-hours and emergency care encounters; prescribed medicines; and adverse reactions and allergies. Plans are underway to allow the recording of diagnosis and to manage prescription medicines within the shared record. All primary care and medical specialist physicians receive laboratory tests and medical images electronically. 42. In Latvia, the United Electronic Health Information System is a national system that is expected to become available in The system is authorised by regulation and will be mandatory for health care institutions and pharmacies. By the end of 2016, health care institutions and pharmacies will be required to conclude a contract with the National Health Service and commence using e-prescription and e-sick-leave 14

16 functions. On 1 July, 2017, other functionalities of the Electronic Health Record System, such as e-referral and patient summaries will be required. s will be able to access the system via an e-health portal, and health care institutions and pharmacies will access the system via the e-health portal or a web-based data exchange with the organisations information system. 3 Currently in Latvia, electronic sharing of patient data occurs mostly within single medical institutions and hospitals. It is common practice for laboratory results to be provided back to referring physicians electronically. In some cases, medical images are shared among medical institutions. 43. In Slovakia, a country-wide electronic health record system has been implemented and is undergoing pilot testing in In Slovakia today, many primary care and medical specialist physicians receive laboratory test results electronically and some receive images electronically. Slovakia is developing its system to allow for the sharing of patient consolidated medications lists and the sharing of patient records among physicians, between physicians and hospitals, and among hospitals. 44. Norway is developing a strategy for an integrated national EHR system which includes the sharing of health information among all health care providers, integrated decision-support systems, and a patient administrative system. Norway has already implemented a national eprescription system. A summary care record is being used for acute and elective care in hospitals and is available for use in primary care, although adoption in this sector is low. The summary care record is a web based system which extracts information from the population registry, primary care, hospital and eprescription databases. Norway also has an electronic messaging system with semi-structured content standards. 45. Greece has national information sharing for instructions and ereferrals for prescription medications by primary care and medical specialist physicians. The national system for eprescribing in Greece is web-based. 46. A business case is awaiting approval to launch the national electronic health record system in Ireland. 4 Primary care physicians and a minority of medical specialists in Ireland are able to receive laboratory test and medical imaging results electronically and to make ereferrals for hospital appointments. Some hospitals also have electronic ordering of tests and images. There is a national project to enable the secure exchange of information among hospitals, health care agencies and primary care physicians National EHR system with sub-national exchange of comprehensive records 47. A few countries have one national EHR system, but within it, some key aspects of record sharing are sub-national only, such as within provinces, states, regions or networks of health care organisations (Austria, Canada, Sweden, Spain and Switzerland; Table 3). Among them, all but Canada, have implemented or are implementing a national information exchange that enables key elements to be shared country-wide. 48. In Austria, there is one national system that virtually links patient records through a national health information exchange. The system enables physicians and hospitals to receive laboratory test results, medical imaging results and hospital discharge letters electronically. The sharing of electronic patient or medical records is at a regional level. 3 The manager of the system is National Health Service ( The development of the system was started in 2009/2010 and it will be available for patients, health care institutions and pharmacies in See 15

17 49. In Sweden, the National Summary provides an overview of patient data by virtually linking connected EMRs and does not store the summary data. In Sweden, patient data is mainly being shared between different care units (hospitals and primary care) within the same health authority (county council). In most cases, care givers contracted by the health authority may share patient data with other health care providers within the health authority s system. 50. Spain has a National Health Record System in order to enhance interoperability of clinical information systems among regions. The aim is to facilitate access to electronic clinical information regardless of the location in which the patient demands healthcare, increasing healthcare quality as well as patient safety. In Spain, a central national node acts as a hub for messaging services between Health Services in each territory. Territorial nodes concentrate EHR information from diverse systems through integration platforms that are managed by each healthcare authority. Document coverage is not yet complete; however it progresses significantly each year. It includes a selection of 9 document types, and is not covering all documents that are available in local systems. In Spain, electronic information sharing is mostly within health centres and primary care networks or within hospitals and hospital networks. In some regions, hospitals share records with a central record system including clinical summaries and, in some cases, laboratory test and medical imaging results and other reports. 51. In Switzerland, the national EHR law was approved in summer 2015 and will come into force in The law enables health data exchange among health care institutions at the national level. Health care providers (primary care physicians, hospitals and others) are required to become certified before being granted access to a secure national health data exchange system. Participation in the system is not mandatory for patients and the exchange of patient data is subject to patients consent. Statutory health service providers are obliged to join the system after a transition period of 3-5 years (depending on the type of institution). For primary care physicians, participation in the platform is voluntary. Health data in the system will remain at the regional/local level. In the current situation in Switzerland, about two-thirds of primary care physicians use their electronic systems primarily for administrative purposes (e.g. billing). There are some regional projects enabling primary care physicians to access patient data repositories within hospitals. Primary care physicians receive laboratory test and medical image results electronically. 52. In Canada, health care is a provincial/territorial responsibility and each of the thirteen jurisdictions has their own Electronic Health Record (EHR) deployment project underway. While there is no national EHR system, many jurisdictions have modelled their system according to a common blueprint established by Canada Health Infoway. General practitioners in some Canadian provinces and territories access patients lab tests, images and prescription medications, and receive hospital discharge summaries and some can also request medications, lab tests, and images electronically. In 2014, a national survey indicated that about 82% of primary care physicians and 78% of medical specialists had an electronic interface to request and receive laboratory and medical imaging results. The majority of primary care and medical specialist physicians, however, did not report an external interface to pharmacies, nor a provincewide exchange of medication information among care providers. Most primary care and specialist physicians can, however, connect directly to provincial/territorial drug information systems where the pharmacies record dispensed information. The most common form of electronic sharing of data by hospitals is the sharing of discharge summaries and other clinical documents with primary care physicians. For example, the Connecting Ontario system brings together local, regional and provincial assets in different parts of the province -- connecting them to improve patient care Limited Record sharing in most countries that are not aiming toward a national system 53. Seven countries indicated that they are not aiming to implement an EHR system at the national level at this time (Chile, Croatia, Czech Republic, Denmark, Japan, Mexico, and the United States; Table 3). Croatia and Denmark report aspects of record sharing that are comprehensive at the 16

18 national level. In the other countries, sharing arrangements differ among health care organisations or regions. 54. In Denmark, the five regions are responsible for hospitals and the implementation of the EHR system is a regional responsibility. Each region has implemented a coherent system and are able to exchange large amounts of information through a joint information exchange infrastructure and the integration of platforms. Danish patients can access their own health information from all parties through a joint portal "sundhed.dk". Danish primary care and medical specialist physicians can access a comprehensive electronic health record for their patients and are able to send and receive laboratory tests and send prescriptions. All primary care and medical specialist physicians use eprescribing in Denmark. Further they have electronic communication with hospitals, other physicians and specialists, physiotherapists and municipalities. The five regions have also implemented a joint EPR for the acute-care sector. All hospitals electronically share all discharge summaries, outpatient notes, casualty-ward notes, laboratory test orders, and laboratory test and medical image results between and among hospitals and with primary care and medical specialist physicians. These records are electronically accessible for professionals and patients through a national repository. Fully updated medication lists are shared automatically among hospitals and primary care and medical specialist physicians, and with patients, through a national medication database that includes medications dispensed by private (non-hospital) and hospital pharmacies. Medical image results are currently shared regionally, however, a national repository is being implemented. 55. Croatia enables primary care physicians to request eprescriptions and to submit ereferrals to laboratories and to medical specialists in hospitals for diagnostic procedures. Pharmacies receive eprescriptions and send dispensation information to a central system. Laboratories and hospitals return efindings to the system, which are then retrieved by the primary care physician offices. Medical specialists in Croatia also benefit from e-referrals for laboratory tests and medical images but rarely share diagnostic and other medical record information with other physicians. More advanced hospitals can store and exchange documents such as ereferrals and efindings. 56. In Chile there is sharing of patient records among primary care physicians within healthcare districts where the physicians have the same EMR system. These systems may also allow ereferrals to medical specialists. 57. In the Czech Republic there may be some information sharing at the local level of lab test and medical image results and some interconnection among providers with the same EMR vendor. Multihospital health care providers in the Czech Republic share the same health information system within their respective hospitals. There are common national solutions for secure information and medical image exchange. 58. In Japan, the national strategy aims to implement the sharing and viewing of electronic records including examinations, prescription medicines and medical images at a sub-national level. For the new Japanese cancer registry, however, there is one national electronic system to gather the data. In Japan, sharing capabilities vary among the bodies implementing EMR systems, such as local governments, Prefectural Medical Associations or incorporated associations. Within these systems there may be sharing and viewing of medical record information among primary care physicians, medical specialists and hospitals and including prescription medicines and laboratory and medical imaging results. There is a nationally standardised format for the storage of hospital data including examination details and prescription medicines. 17